Provider Demographics
NPI:1336203892
Name:STATE OF NEVADA
Entity type:Organization
Organization Name:STATE OF NEVADA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:775-687-5162
Mailing Address - Street 1:1665 OLD HOT SPRINGS RD STE 157
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706-0663
Mailing Address - Country:US
Mailing Address - Phone:775-687-5162
Mailing Address - Fax:775-687-5745
Practice Address - Street 1:1665 OLD HOT SPRINGS RD STE 157
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89706-0663
Practice Address - Country:US
Practice Address - Phone:775-687-5162
Practice Address - Fax:775-687-5745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV005413091Medicaid
NV03813096Medicaid
NV03813092Medicaid